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KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY
COLLEGE OF HEALTH SCIENCES
SCHOOL OF MEDICAL SCIENCES
DEPARTMENT OF COMMUNITY HEALTH
ASSESSMENT OF KNOWLEDGE, ATTITUDES AND PRACTICES
TOWARDS INGUINAL HERNIA AMONG ADULT-MALES IN THE EAST
MAMPRUSI DISTRICT
BY
TIA ROBERT SULE
SEPTEMBER, 2014
2
KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY
COLLEGE OF HEALTH SCIENCES
SCHOOL OF MEDICAL SCIENCES
DEPARTMENT OF COMMUNITY HEALTH
ASSESSMENT OF KNOWLEDGE, ATTITUDES AND PRACTICES
TOWARDS INGUINAL HERNIA AMONG ADULT-MALE IN THE EAST
MAMPRUSI DISTRICT
A THESIS SUBMITTED TO THE DEPARTMENT OF COMMUNITY
HEALTH, KWAME NKRUMAH UNIVERSITY OF SCIENCE AND
TECHNOLOGY, KUMASI IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE DEGREE OF MASTERS OF PUBLIC HEALTH
(MPH) IN HEALTH EDUCATION AND PROMOTION
BY
TIA ROBERT SULE
SEPTEMBER, 2014
i
DECLARATION
I hereby declare that except for references to other people„s work which have been duly
acknowledged, this work is the result of the original research work taken by me under
supervision. It contains no materials previously published by another person which has
been accepted for the award of any degree elsewhere.
TIA ROBERT SULE (PG ……………………)
...…………………
Signature
................................
Date
MR. EMMANUEL K NAKUA
(Supervisor)
...…………………
Signature
................................
Date
DR. ANTHONY K. EDUSEI
(Head of Department)
...…………………
Signature
................................
Date
ii
DEDICATION
I dedicate this thesis to my daughter Azabu-Tia Greenway and my brother Mr. Tia
Joseph Azabu for their love and supports for me.
iii
ACKNOWLEDGEMENT
I am very grateful to the Almighty God for His divine help and protection throughout
my stay on KNUST campus and for the knowledge He gave me to finish this
programme successfully.
My special thanks go to my supervisor Mr Emmanuel Nakua, for the excellent
supervision I had from him during the entire duration of this work.
I am also grateful to my research assistants Messrs: Nantomah Bismark, Musah
Mohammed, and the medical team namely James Koligu Jasinfa, Seth Ziba, and Dr
Emmanuel Bidzakin for the useful comments and contributions they made individually
and collectively to guarantee the success of this work.
My profound gratitude also goes to my Lovely wife Constance Azabu-Tia for her
wonderful supports and contributions towards the success of this work.
I also dully acknowledge the contributions of my class mates, friends and family.
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LIST OF ABBREVIATIONS/ACRONYMS
CAM Complementary Alternative Medicine
CBOs Community Based Organisations
DHS Demographic and Health Survey.
FP Family Planning.
GD Ghana Districts
GDHS Ghana Demographic and Health Survey
GFTMPA Ghana Federation of Traditional Medicine Practioners
Association
GSS Ghana Statistical Service
HHP Harvard Health Publications
HLB Healthy lifestyle behaviour
KAP Knowledge, Attitudes and Practices
KATH Komfo Anokye Teaching Hospital
KNUST Kwame Nkrumah University of Science and Technology
MDG Millennium Development Goal
MOH Ministry of Health
NGOs Non-Governmental Organizations
OPD Out- Patient Department
RH Reproductive Health
SPSS Statistical Product for Social Solutions
TMP Traditional Medicine Practitioner
TMU Traditional Medicine Unit
TP Target Population
v
WHO World Health Organization
WIRA Women in Reproductive Age
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TABLE OF CONTENT
DECLARATION ............................................................................................................. i
DEDICATION ................................................................................................................ ii
LIST OF ABBREVIATIONS/ACRONYMS .............................................................. iv
TABLE OF CONTENT ................................................................................................ vi
LIST OF TABLES ........................................................................................................ ix
LIST OF FIGURES ....................................................................................................... x
ABSTRACT ................................................................................................................... xi
CHAPTER ONE ............................................................................................................. 1
1.0 INTRODUCTION .................................................................................................... 1
1.1 Background information ........................................................................................... 1
1.2 Statement of the problem .......................................................................................... 3
1.3 Justification for the study .......................................................................................... 5
1.4 Research Questions ................................................................................................... 5
1.5 Study Objectives ....................................................................................................... 6
1.5.1 Main Objective .................................................................................................... 6
1.5.2 Specific objectives ................................................................................................... 6
1.6 Conceptual framework .............................................................................................. 6
CHAPTER TWO ............................................................................................................ 9
2.0 LITERATURE REVIEW ........................................................................................ 9
2.1 Background ............................................................................................................... 9
2.2 Misconceptions (Knowledge) about inguinal hernia ................................................ 9
2.3 Attitudes of people towards inguinal hernia and people living with inguinal
hernia ..................................................................................................................... 10
2.4 Perceptions (fears and barriers) people have about surgical treatment of
inguinal hernia ....................................................................................................... 12
2.5 Practices related to the management or treatment of inguinal hernia ..................... 12
CHAPTER THREE ..................................................................................................... 15
3.0 METHODOLOGY ............................................................................................... 15
3.1 Introduction ............................................................................................................. 15
vii
3.2 Study Methodology................................................................................................. 15
3.3 Study Site ................................................................................................................ 15
3.4 Study Population ..................................................................................................... 16
3.5 Sample Techniques and Sample Size ..................................................................... 16
3.6 Data collection and study instrument...................................................................... 17
3.7 Study Variables ....................................................................................................... 18
3.8 Ethical Considerations ............................................................................................ 19
3.9 Assumptions of Study ............................................................................................. 20
3.10 Limitations of Study ............................................................................................... 20
3.11 Pre-testing ............................................................................................................... 20
3.12 Data Handling and processing ................................................................................ 21
3.13 Data Analyses ......................................................................................................... 21
CHAPTER FOUR ........................................................................................................ 22
4.0 RESULTS .............................................................................................................. 22
4.1 INTRODUCTION ................................................................................................. 22
4.2 BACKGROUND CHARACTERISTICS OF RESPONDENTS ........................... 22
4.3 PROPORTION OF RESPONDENTS WITH INGUINAL HERNIA .................... 24
4.4 ATTITUDES OF THE PROPORTION OF RESPONDENTS WITH
INGUINAL HERNIA TOWARDS SURGICAL TREATMENT. ....................... 24
4.5 HEALTH BEHAVIOURS ...................................................................................... 26
4.6 KNOWLEDGE ABOUT INGUINAL HERNIA ................................................... 26
4.7 ATTITUDE TOWARDS INGUINAL HERNIA DIAGNOSIS ............................. 27
4.8 ATTITUDES TOWARDS INGUINAL HERNIA TREATMENT ........................ 28
4.9 MISCONCEPTIONS ABOUT INGUINAL HERNIA TREATMENT ................... 31
CHAPTER FIVE .......................................................................................................... 34
5.0 DISCUSSION ......................................................................................................... 34
5.1 Introduction ............................................................................................................. 34
5.2 Knowledge about Inguinal Hernia .......................................................................... 34
5.3 Attitude towards the Diagnosis and Treatment of Inguinal Hernia ........................ 35
5.4 Misconception about treatment of inguinal hernia ................................................. 36
5.5 Practices related to inguinal hernia occurrence ...................................................... 37
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CHAPTER SIX ............................................................................................................. 38
6.0 CONCLUSIONS AND RECOMMENDATIONS ............................................... 38
6.1 CONCLUSIONS .................................................................................................... 38
6.1.1 Prevalence of Inguinal Hernia in the East Mamprusi District............................... 38
6.1.2 Misconceptions (knowledge) about the causes of inguinal hernia ........................ 38
6.1.3 Attitudes towards inguinal hernia and people living with inguinal hernia............ 39
6.2 Recommendations ................................................................................................... 39
REFERENCES ............................................................................................................. 41
APPENDICES .............................................................................................................. 47
APPENDIX A ............................................................................................................... 47
APPENDIX B ................................................................................................................ 62
ix
LIST OF TABLES
Table 3.1: Number of inguinal hernia repairs (January-December 2013) at the East
Mamprusi District Hospital, Baptist Medical Centre; Nalerigu. ................... 16
Table 3.2: Operationalization of study Variables ........................................................... 18
Table 4.1: Socio-demographic characteristics of respondents ........................................ 23
Table 4.2: Attitudes of the proportion of respondents with inguinal hernia towards
surgical treatment. .......................................................................................... 25
Table 4.3: Health Behaviors of the Respondents ............................................................ 26
Table 4.4: Knowledge about Inguinal Hernia ................................................................ 27
Table 4.5: Attitude towards diagnosis of inguinal hernia ............................................... 28
Table 4.6: Attitude towards inguinal hernia treatment. .................................................. 30
Table 4.7: Misconception about treatment of inguinal hernia ........................................ 32
x
LIST OF FIGURES
Figure 1.0 Conceptual framework for Knowledge ,Attitudes and Practices towards
Inguinal Hernia ................................................................................................................. 8
Figure 4.1 Prevalence of Inguinal Hernia .................................................................. 24
Figure 1.0 Map of the East Mamprusi District showing the study towns. ..................... 63
xi
ABSTRACT
Globally, inguinal hernia is the most common type of hernia, comprising of
approximately 75% of all abdominal wall hernias. It is one of the most common general
surgical operations worldwide accounting for 10 to 15% of all surgical procedures.
There is paucity of published data on the knowledge, attitudes and practices towards
inguinal hernia in our environment as there is no local study which has been done in the
East Mamprusi District.
This study was a community-based cross-sectional study with the aim of assessing the
knowledge, attitudes and practices towards inguinal hernia in the East Mamprusi
District among adult-males. A sample of 216 respondents was selected through a multi
stage sampling technique.
It was revealed that the knowledge about inguinal hernia was inadequate, even though
majority (61.6%) attributed the cause of inguinal hernia to hereditary factors, with more
than half (52.7%) reporting food/drink to be the cause. Majority (34.5%) indicated they
would prefer to see a medical doctor upon suspicion of inguinal hernia, with 1.4%
reporting that they would rather inform a priest/pastor about the medical condition in
question. The predominant attitude towards the treatment of inguinal hernia was found
to be fear of surgery (28.8%), followed by adverse effects of surgery (25.4%) and high
hospital cost (24.5%). About one-fifth believed inguinal hernia is as a result of
ancestral curse. Eighty percent of the respondents reported to have ever engaged in
heavy lifting, with almost an equal proportion (84.1%) reporting the frequency of
lifting to be occasional.
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The study indicates inadequate knowledge about inguinal hernia among adult-males in
the East Mamprusi District. Intervention programmes by stakeholders particularly the
East Mamprusi District Health Directorate could, therefore, address the issue of
inadequate knowledge about the condition by intensifying IEC programmes in the
communities.
1
CHAPTER ONE
1.0 INTRODUCTION
1.1 Background information
An inguinal hernia is a “condition in which intra-abdominal fat or part of the small
intestine, also called the small bowel, bulges through a weak area in the lower
abdominal muscles. An inguinal hernia occurs in the groin –the area between the
abdomen and thigh. This type of hernia is called inguinal because fat or part of the
intestine slides through a weak area at the inguinal ring, the opening to the inguinal
canal. An inguinal hernia can occur anytime from infancy to adulthood and is much
common in males than females” (NIH, 2008).
Inguinal hernias are categorized in to two: indirect and direct inguinal hernias. In the
former, herniation results from congenital circumstances and is much more common in
males than females owing to the way males develop in the womb. In a male fetus, “the
spermatic cord and both testicles-starting from an intra-abdominal location-normally
descend through the inguinal canal in to the scrotum, the sac that holds the testicles”
(NIH, 2008).This explains, in part, why males are more susceptible to suffer indirect
inguinal hernia. As a matter of fact, indirect inguinal hernias are the most commonly
occurring inguinal hernias and even premature infants are particularly at risk of indirect
inguinal hernias. This is true with premature infants because there is usually less time
for the inguinal canal to close shortly after birth.
The inguinal canal is a passageway through the abdominal wall near the groin. Indeed,
inguinal hernias are up to ten times common in men than it is the case with women. It is
equally important to observe that indirect inguinal hernias are diagnosed within the
2
early years of life and may not show up until adulthood. Indirect inguinal hernias
affects between 1% and 5% of normal newborns and up to 10% of premature infants.
Direct inguinal hernias are more common in adults, but less so with children (HHP,
2013).
Globally, inguinal hernia is the most common type of hernia, comprising of
approximately 75% of all abdominal wall hernias (Garba, 2000; Williams et al., 2008).
Inguinal hernia repair is one of the most common general surgical operations
worldwide accounting for 10 to 15% of all surgical procedures and is the second most
common surgical procedure after appendectomy (Schools et al., 2001). It has been
estimated that worldwide over 20 million repairs of inguinal hernia are carried out each
year, the specific operation rates varying between countries from around 100–300 per
100,000 population per year (Kingsnorth and LeBlanc, 2003). In the United Kingdom
some 100,000 inguinal hernias are repaired each year and approximately 750,000
inguinal hernias are repaired each year in the United States (Rutkow, 2003).
Inguinal hernia has generally been overlooked as a public health priority in Africa, with
its high prevalence largely unrecognized, and traditional public health viewpoints
assuming that not enough infrastructure, human resources, or financing capacity are
available for effective service provision.
In sub-Saharan Africa, the epidemiologic and clinical picture of hernia is somewhat
different. Although an estimated 7.7% of adult men in rural southern Ghana had
inguinal hernia during the 1970s, the prevalence of this condition was found to be as
high as 30% on the island of Pemba in East Africa in 1969 (Belcher et al., 1978;
Yardov and Stoyanoy, 1969). Current data on hernia prevalence and incidence in Sub-
Saharan Africa are lacking. Most cases therefore go untreated in resource-poor settings,
3
resulting in massive, painful hernias that often preclude engaging in work (Shillcutt et
al., 2010; Harouna et al., 2000). Recent research indicates that up to two-thirds of
inguinal hernias are repaired under emergency conditions in Ghana, resulting in
increased costs both to the patient and medical system (Rutkow, 2003). Whereas hernia
complications are rarely deadly in wealthy countries, mortality from hernia
strangulation even with access to surgical care is 40% in Niger (Hair et al., 2001).
Complications of inguinal hernia include incarceration, bowel obstruction, and bowel
strangulation (which is potentially fatal), with the greatest risk being found among
older persons. Although risk of death is small, hernia deaths was listed as the
underlying cause of death for 1,595 people in the US in 2002 (Kochanek, 2002).
Two studies found increased risk with strenuous exertion to be one of the major risk
factors of hernia (Flich et al., 1992; Carbonel et al., 1993). Interestingly, being
overweight was associated with lower risk in two studies (Abramson et al., 1978;
Carbonel et al., 1997). Associations with inguinal hernia were found in individual
studies for varicose veins (Abramson et al., 1978), history of haemorrhoids (Abramson
et al., 1978), smoking (Sorensen et al., 2002), and hiatal hernia (De Luca et al., 2004).
1.2 Statement of the problem
Inguinal hernia repair is one of the commonest surgical operations in Africa. An
estimated 175 people per 100000 require hernia repair in Africa every year. Indeed,
there is a reported prevalence estimates as high as 1400 per 100,000 in Carpenter,
Ghana (Kingsnorth unpublished work, 2008, cited in Shillcut et‟al 2010). Admittedly,
significant successes have been chalked in greater Accra, for example, strangulated
inguinal hernia remains a big problem in rural settings owing to either dear or
4
unavailability of simple surgical services (Samuel D. et al, 2010). Additionally, the
prevalence of inguinal hernia in Ghana is 7.7% of the population. But the elective
operation rate is significantly lower due to the fact that many of the hernias are repaired
as emergency cases only. This unfortunate discrepancy calls for a pool of longstanding
large hernias in Ghana (Sanders et al 2008).
There have been little or absolute dearth of publications in various communities in
Africa especially in Sub-Saharan Africa on surgical diseases. There is, therefore, little
or non-existent population-based studies about the epidemiology of inguinal hernias
except dozens of work on hospital-based (clinical) studies that do not reflect the true
burden of groin (inguinal) hernias among Africans. For the most part, deaths from
surgical diseases are often recorded as other cause of death (Ohene-Yeboah, 2011).
Moreover, inguinal hernia repair has been largely undermined as a great public health
concern in Africa. As a result, its high prevalence remains unrecognized. African
governments have often cited inadequate infrastructure, human resources (nurses and
doctors), inadequate financing as the underlying reasons for ineffective service
provision for surgical diseases including inguinal hernias. Clearly, emerging evidence
suggests that inguinal hernias in Ghana are nearly ten (10) times as prevalent as in high
income countries (Kingsnorth, 2009)
A study on the knowledge, attitudes and practices regarding inguinal hernia would
provide available epidemiological data that may inform decisions and efforts required
in order to reduce the burden of hernia in Africa (Ohene-Yeboah, 2011).
5
1.3 Justification for the study
The study would provide the platform upon which need for surgical diseases such as
inguinal hernia would be taken seriously at all levels of the health system in Ghana and
beyond.
Again, the study would bring to the limelight the need to offer health education on
surgical diseases such as inguinal hernia at all levels of national life such as school
health education programme as it is the case with other diseases such as HIV/AIDS.
The study would also bring to the fore the prevalence rate of inguinal hernia and or the
case load of inguinal hernia in the East Mamprusi district of the northern region of
Ghana.
The study further seeks to provide ample data on inguinal hernia in Ghana so as to
augment the limited population –based literature on surgical diseases including inguinal
hernia in West Africa and beyond.
Lastly, the study would help remove some of the misconceptions that many a people
have about inguinal hernia as well as reduce the social stigma associated with the
disease under consideration- inguinal hernia.
1.4 Research Questions
1. What beliefs do people hold about the causes of inguinal hernia?
2. Which alternative sources of care are available for people who delay surgical
care for inguinal hernia?
3. What is the attitude of people towards inguinal hernia and people living with
inguinal hernia?
4. What is the prevalence rate of inguinal hernia in the East Mamprusi District?
6
1.5 Study Objectives
1.5.1 Main Objective
The main objective of this study was to assess the knowledge, attitudes and practices
towards inguinal hernia among adult-males in the East Mamprusi District.
1.5.2 Specific objectives
1. To identify misconceptions (knowledge) people have about the causes of inguinal
hernia,
2. To examine the perceptions (fears/barriers) people have about surgical treatment of
inguinal hernia,
3. To assess the attitudes of people towards inguinal hernia and people living with
inguinal hernias, and
4. To assess the practices related to the management or treatment of inguinal hernias.
1.6 Conceptual framework
Theoretical frameworks may be defined as “a group of theories that underpin research.
They can be considered as statements that predict the relationships among variables,
and assist in guiding the choice of research strategy and methods that will be used”
(GAC, 2006).A conceptual framework on the other hand is the operationalization of the
theoretical framework. The conceptual framework may summarize the major dependent
and independent variables in the research and the relation between them” (Stewart,
2013). It follows, then, that theoretical frameworks provide the seed bed necessary for
the seeds of conceptual framework to germinate. In other words, theoretical framework
is the mother of conceptual framework.
7
The basic tenet of this framework is the examination of the influence that personal
beliefs have on the overall health behavior (s) of individuals.
Thus, the model is helpful in offering counseling to persons who have inguinal hernia
to adopt healthful attitudes (actions) towards inguinal hernia and the need to seek early
surgical repairs of hernia. The values and beliefs of individuals or the attitudinal system
of a society as shown in the conceptual framework work singly or in combination to
influence the health behavior of humans. In this framework (as shown in figure 1.0)
certain variables need to be explained. Exposure refers to strategies that promote
positive behavioral outcomes such as the mass media, school and community health
education on inguinal hernia. The setting, age, gender and self-control determine the
susceptibility of an individual to the condition of inguinal hernia. Setting refers to the
locality (urban or rural) and self-control underlie the ability of individuals to avoid acts
that make them liable to getting inguinal hernia or to go by post-surgery pieces of
advice to avoid recurrence of inguinal hernias. For example, it has been reported that
most adults are usually advised against heavy lifting and vigorous activity for a number
of weeks (NIH, 2008).
Thus, the framework seeks to change the beliefs and emotions aspects of the attitudinal
system by manipulating knowledge through exposure. If the exposure strategies are
successful then there would be positive outcomes on the knowledge, attitudes and
practices of the people towards inguinal hernia (GAC, 2006). Knowledge represents the
misconceptions or poor understanding that people have about the causes of inguinal
hernia. The variable attitudes also refers to the degrees of fear or perceptions that
people nurse or have for accessing surgical care/treatment for inguinal hernia as well as
8
reactions towards inguinal hernia and people living with inguinal hernia. The variable
practices represent indigenous methods or activities (such as traditional medicine
practices) that expose people to the condition of inguinal hernia and local knowledge of
the people in treating or managing the condition of inguinal hernia. The conceptual
framework is guided by certain assumptions: first, individuals are not born with the
attitudes (attitudes are learnt) that they have towards diseases such as inguinal hernia.
Also attitudes die hard and are not easy to change. Attitudes thus make us unwilling or
willing to seek surgical care and also to despise those who have (large-size) inguinal
hernias (GAC, 2006). Knowledge influences attitudes which in turn influence practices
as shown in Figure 1.0 by the double arrows between Exposure and Knowledge.
Figure 1.0 Conceptual framework for Knowledge ,Attitudes and Practices towards
Inguinal Hernia
Source: Ghana AIDS Commission (2006).
9
CHAPTER TWO
2.0 LITERATURE REVIEW
2.1 Background
Knowledge, Attitudes and Practices (KAP) studies are carried out in order to
investigate human behavior as regards a certain topical issue. KAP studies identifies
what people know (Knowledge), how the people feel (Attitude) and what the people do
or Practice (Ellen, 2009).
Literature review for this study was subsumed under the following four broad headings:
(i) Misconceptions (knowledge) about the causes of inguinal hernia
(ii) Perceptions (fears / barriers) people have about surgical treatment of
inguinal hernia
(iii) Attitudes of people towards inguinal hernia and people living with inguinal
hernia
(iv) Practices related to the management or treatment of inguinal hernias
2.2 Misconceptions (Knowledge) about inguinal hernia
It is said that knowledge, and therefore education, is one of the fundamental capabilities
that a person needs to make a sense of oneself and the world one lives in. It enables him
or her to comprehend, compare, analyse, communicate, relate to, act upon, and assess
the self, and the nature of their fellow human beings.
In many developing countries, lack of awareness and financial constraints make many
patients present very late with giant inguinoscrotal hernia which is a serious life-
threatening condition (Osifo and Amusan, 2010). As in other studies done in other
developing countries (Osifo and Amusan, 2010; Rai et al., 1998; Nesterenko and
10
Shovskii, 1993), financial constraints and lack of awareness were reported as the most
common reasons for the late presentation in our study.
Admittedly, misconceptions about diseases are not synonymous with inguinal hernia
alone. It is same with many other diseases of humankind such as malaria, TB,
HIV/AIDs, Anaemia and the like. Among the Kasena-Nankana and Bulsa in the Upper
East region of Ghana, for example, it is believed that groin or inguinal hernia, genital
hydrocele and elephantiasis are the result of febriele condition known as „Pua’ in their
dialect. Their justification for this view is that people who suffer from hernia, hydrocele
and elephantiasis experience acute fevers and body pains (Adongo et‟al, 2005).
In a related study, it has been observed that urogenital diseases such as hydrocele is
caused by genetic factors as well as over consumption of sweet drinks such as palm
wine or over riding of bicycles(Evans et‟al 1993 cited in Frimpong, ,2010).
2.3 Attitudes of people towards inguinal hernia and people living with inguinal
hernia
People living with inguinal hernia have suffered various kinds of stigma and
discrimination in many parts of the world. In a study on giant hydrocele associated with
inguinal hernia in South Sudan; it was revealed that public ridicule to victims of these
conditions of giant hydrocele and inguinal hernia has been a major problem. In that
people living with these conditions either had difficulties to marry or remained
unmarried for life. As a result, victims of inguinal hernia and hydrocele are considered
infertile and worthless. This further makes people living with inguinal hernia to hide
their positive status until they became gangrenous and gigantic resulting in emergency
11
treatments or deaths. Thus, people with these conditions have severe psychological
traumas rather than physical problem (Salih, 2008).
Another study found that urogenital disorders such as hydrocele and inguinal hernia are
sources of social stigma, lower chances for employment, problems with sexual
activities, physical deformation, and loss of work due to daily or frequent attacks of
fever, pain, adenolymphangitis and low self-esteem or confidence (WHO, 2002).
In a related study, victims of giant hydrocele and inguinal hernia were reported to have
poor health-seeking behavior. In that people living with inguinal hernia were either
negligent about their conditions, ignorant about the side effects or complications
associated with their conditions, fear of impotency and death from surgical repairs of
their conditions (Salih, 2008).
Across the globe, urogenital diseases have often been associated with contempt. In
India, for example, an unfortunate vulval fibroma that assumed the form or shape of a
male scrotum resulted in the patient‟s husband divorcing her on the grounds of sexual
ambiguity (Sanjoy et‟al, 2012).
It is common knowledge among the Mamprusi of the Mole-Dagbani ethnic group in the
northern region of Ghana that any persons of royal descent who are unfortunate to have
physical defects cannot become or aspire to become the king of Mamprugu. That is to
say that a royal may not lack an eye, a nostril, a finger, a toe, an ear as well as swelling
of the body including inguinal hernia ,blindness and insanity. As a matter of fact, any
such persons with these defects are said to have suffered from misuse of an oath or an
offence to the ancestors (Drucker, 1975).
12
2.4 Perceptions (fears and barriers) people have about surgical treatment of
inguinal hernia
The barriers to accessing and demanding surgical care revolve around three important
categories: socio-cultural, financial and structural. Structural (availability) factors refer
to the location of facilities of health care and the readiness and capability of the
available health services to the health needs of the population. The financial barriers
involve both the direct and the indirect costs of accessing health care. Lastly, the socio-
cultural factors underlie the beliefs, expectations and perceptions that people have
about surgical care (Caris et‟al, 2011).
In a related study, insufficient resources, inappropriate allocation of health care
facilities, inadequate quality of manpower and tools are great obstacles to the demand
and supply of health care that reaches the poor. Access to health care in developing
countries depends on four (4) dimensions of the word “access”: availability,
accessibility, affordability and acceptability. Clearly, the demand and supply factors are
also supremely important in trying to understand access to health care. On the demand
side, cultural and educational factors may prevent the realization of illness and the
associated benefits from seeking health care, while economic constraints might
suppress proper utilization of health services available. Turning to the supply side,
unwillingness to provide appropriate interventions deny people access to health care
(O‟Donnell, 2007).
2.5 Practices related to the management or treatment of inguinal hernia
Globally, literature indicates that the percentages of people who adopt healthy lifestyle
behaviour (HLB) are disappointing (Eshah, 2011). In a study conducted by Eshah
13
(2011) to identify the level of adoption of HLB in Jordanians and to compare the
socio-demographic and reported clinical history based on the HLB adoption level, it
was revealed that participants were not adopting HLB regularly. Women, the
married, the educated, and those having higher income had a higher HLB adoption
level.
The high rate of both varicose veins and haemorrhoids in developed countries has been
attributed to the consumption of refined foods, through the effects of straining at stool
or the exertion of local pressure by the loaded bowel (Burkitt, 1972).
Traditional medicine provides the best possible alternative to about 70% of Ghana‟s
population. During the colonial era the only recognized medical system was allopathic.
However, after independence successive governments recognized the need for
Complementary Alternative Medicine (CAM). As a result, there is one Traditional
Medicine Practitioner (TMP) for every four hundred (400) people and a corresponding
ratio of one allopathic doctor for every 12000 people. In Ghana, TMPs use various
kinds of herbs, spiritual beliefs and, above all, local wisdom in offering health care to
the sick (WHO, 2001).
The need for traditional medicine is weighty to the extent that in 1991 the Traditional
Medicine Unit (TMU) was created under the Ministry of Health (MOH), and the unit
was revised in to a full directorate under the MOH in Ghana. Better still; the various
associations of traditional and alternative medicine were combined in to one unit
known as the Ghana Federation of Traditional Medicine Practioners Association
(GFTMPA).
Ghana has roughly 45000 traditional healers. Admittedly, it is the rural communities
that serve as the mecca of traditional medicines and the greatest consumers of
14
traditional products and healings. This unfortunate “popularity” for consumption of
herbal products stems from the difficulty or high cost of mainstreaming traditional and
alternative medicines in to the national health care system , doctor shortages
(inadequate manpower ) and deep-seated spiritual beliefs that are used to define the
causes of diseases(Antoinette,2010).
In China, for example, Acupuncture and herbal treatment are some of the natural ways
of treating inguinal hernias. The treatment of inguinal hernia with Acupuncture
“involves inserting small needles in to the lower abdominal region to relieve pain and
aid the qi [life‟senergy] in the liver channels. Indirect moxibustion is also used in distal
acupuncture on points on the liver and spleen channels. Moxa is then wrapped around
the tip of the needle inserted into an acupoint. The tip of the needle is lit, causing heat
to be generated and applied to the point and surrounding body area. The Moxa is then
extinguished the needle removed after the desired result is reached” (Zohixin, 2011).
Herbs are also used “to move the liver qi, warm the channels, nourish the spleen and
balance yin and yang include: 1.Gotu kola leaf (jixuecao) useful for healing wounds
and as a general tonic
1. Ginseng helps strengthen internal defenses
2. Slippery elm (yushu) and Chamomile (ganju) are both tested and potent cures for
hernia” (Zhixin,2011)
In Northern Ireland, Complementary and Alternative Medicine is used for varying
reasons such as a specific health problem, general health and well-being, leisure or
relaxation. However, the most common health problems that call for the use of CAM
therapy include women‟s health, stress and mental health issues such as anxiety and
depression (McDonough, 2007).
15
CHAPTER THREE
3.0 METHODOLOGY
3.1 Introduction
This chapter presents the methodology and design of the study, a brief description of
the study area, study population, sample size, sampling method, data collection, data
handling, data analysis, ethical consideration(s), assumptions and limitations.
3.2 Study Methodology
A community-based descriptive cross-sectional study design was used to assess the
knowledge, attitudes and practices of people about groin or inguinal hernia. The study
was conducted from October to November; 2013.The study used quantitative methods
to collect data by aid of a structured questionnaire. The study included a medical team
that confirmed positive cases of inguinal hernia and offered recommendations for
repairs at the district hospital in Nalerigu.
3.3 Study Site
The East Mamprusi District is one of the twenty districts in the Northern Region of
Ghana. The capital town is Gambaga. It is located in the north eastern-corner of Ghana
and shares boundaries with the Garu Tempane ,Talensi Nabdam and Bawku West
districts to the North ,Bunpkurugu-Yunyoo district to the East ,West Mamprusi district
to the West and the Gusheigu and Karaga districts to the South (GD,2006).It has a
population of 121,009 comprising 59,453 males and 61,556 females (GSS,2012).The
district has only one hospital located at Nalerigu. There are other health centre located
at Wundua, Langbinsi, Gbintiri, Sakogu and Gambaga and most recently Namangu.
16
The district hospital is the Baptist Medical Centre located at Nalerigu. The most often
reported Out-Patient Department (OPD) disease is Malaria and other complications
such as gynecological problems as well as inguinal hernia among other complications
(GD, 2006).
Table 3.1: Number of inguinal hernia repairs (January-December 2013) at the
East Mamprusi District Hospital, Baptist Medical Centre; Nalerigu.
Source: Unpublished records of the Baptist Medical Centre, Department of
Theatre, Nalerigu-Ghana (2013)
3.4 Study Population
The study population comprised males 15 years and above. The study was conducted in
12 communities in the East Mamprusi district. Respondents who were found to be
positive was given the needed counseling as to the necessity of surgical repair for
hernia and the desired strategies to minimize the risks of incurring inguinal hernias.
However, the research team did not interfere with the decision or choice of the
participants as regards their participation or otherwise.
3.5 Sample Techniques and Sample Size
A multi-stage sampling technique was employed. Estimated sample size of 216
respondents was recruited for this study. The district has over 80 villages and towns.
The primary sampling unit was the household. We visited 200 households and males
were interviewed. For administrative purposes the district is divided in to five zones.
The study was conducted within four of the five zones (towns/area councils) of the
Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov Dec Total
16 25 14 20 34 18 18 17 22 44 24 21 273
17
district namely: Gbintiri, Langbinsi, Gambaga, Sakogu and Nalerigu. In the first Phase,
four of the five zones were randomly selected. The selected communities were
considered as clusters. Probability proportion to size was applied to estimate the
number of respondents that were interviewed in each community. A systematic random
sampling technique, with a sampling interval of three (3) was employed to randomly
select households. The second step involved the researcher choosing a direction in a
random way by spinning a bottle on the ground and then choosing the direction where
the bottleneck pointed to. In the third step, the researcher then walked in the specified
direction of the bottle neck and selected every third household (depending on the size
of the village) until the required 18 households were obtained. In situations where the
boundary of the town/village was reached and the required households were not
obtained, the researcher then returned to the centre of the village and walked in the
opposite direction and continued to select households until the mark was obtained. In
cases where there was nobody in a selected household, the nearest or next household
was considered (WHO, 2004).
3.6 Data collection and study instrument
A structured questionnaire was used for the data collection. The questionnaire was
adopted and modified from the unpublished work of the Department of Surgery of the
Kwame Nkrumah University of Science and Technology (KNUST) and Komfo
Anokye Teaching Hospital (KATH) (KNUST & KATH Unpublished Work, 2013).
The research team consisted of a Medical Officer and two Nurses who confirmed
positive cases of inguinal hernia .Also included were two research assistants and the
principal investigator who administered the questionnaires. The questionnaire was
divided in to five sections. The first part centred on the demographic and socio-
18
economic status of the respondents .The second part elicited responses on the causes of
inguinal hernia, while the third part dwelt on the attitudes towards inguinal hernia
diagnoses. The fourth part focused on the attitudes towards inguinal hernia treatment.
The last part focused on the misconceptions about inguinal hernia treatment.
3.7 Study Variables
Independent Variable: knowledge, attitudes and practices
Dependent Variables: Inguinal Hernia
Table 3.2: Operationalization of study Variables
Variables Defined operations/indicators Scale of
measurement
Sex
Age
Marital status
Knowledge
Attitude
Practices
Misconceptions
Perception
Residents
Male or female
All ages from15 years and above
The state of being married, divorced, separated,
single or widowed.
The understanding that people have about
inguinal hernia
The beliefs and emotions people have about
inguinal hernia and persons living with inguinal
hernia
Activities that expose people in to getting inguinal
hernia.
The knowledge gaps or poor knowledge that
people have about the causes of inguinal hernia.
The degree of fear or hesitations that people nurse
or have about accessing surgical treatment for
inguinal hernia
The inhabitants or people living in the east
Mamprusi district.
Binary
Ordinal
Nominal
Ordinal
Binary
Binary
Binary
Ordinal
Nominal
19
3.8 Ethical Considerations
The interview of the selected respondents commenced with a thorough explanation of
the objectives and purposes of the research in the local language of Mampulli (the
predominant spoken language in the study area) to the participants to feel at home so as
to give off their best in the researcher –respondent interactions. The respondents were
told that their participation or otherwise was voluntary and as such they had the free-
will to do so.
Admittedly, informed consent of respondents was obtained verbally from the research
participants. Additionally, Ethical clearance was obtained from the Committee on
Human Research Publication and Ethics of the Kwame Nkrumah University of Science
and Technology and approval was given before the data was collected on the
participants.
Again, the necessary community entry protocol was observed in all the twelve
communities where the data was collected .This gesture made it possible for the
researcher to explain the purpose or objectives of the research to the gate keepers of
each of the communities visited in order to mobilize their support before going in to the
community to collect data on the specified respondents: household by household.
Lastly, each of the participants was assured of confidentiality, anonymity and other
ethical considerations necessary to promote positive researcher – respondent
relationships throughout the period for the field work.
20
3.9 Assumptions of Study
1. The sample size of 216 participants was assumed to be the true representative sample
of the views of residents in the study area.
2. It was also assumed that the views of all 216 respondents were a true reflection of the
realities on the ground
3. The instruments used were accurate and reliable in capturing the required the data.
3.10 Limitations of Study
The first major limitation of the study was the paucity or limited population-based
literature on the subject of inguinal hernia.
Also, human subjectivity and cultural factors brought about some challenges as the
subject of the data was on the genital area.
Again, the time frame of three months for the research was also too short to come by
the needed output.
Lastly, the medical research assistants used for the field work could not participate in
the entire period of the field work due to heavy workloads on them.
3.11 Pre-testing
The questionnaire for the study was pretested in about 20 households in the Langbinsi
zone of the east Mamprusi district. This process was necessary to allow for certain
modifications of the questionnaire to be done. As a result, some of the questions in the
questionnaire were reworded to cater for inconsistencies, and ambiguities that were
detected during the pretesting exercise.
21
3.12 Data Handling and processing
The questionnaires were stored safely with regard to basic ethical requirements. The
questionnaires were then coded, cleaned, edited and re-entry made so as to guarantee
quality control.
3.13 Data Analyses
The questionnaires were coded before the analysis was carried out. Descriptive analysis
was employed to show the level of knowledge about inguinal hernia among the
respondents. Data was summarized in form of proportions and frequent tables for
categorical variables. Continuous variables were summarized using mean, median,
mode and standard deviation.
STATA version 12 for Windows (STATA Corp., College Station, Texas, United
States) was used for data analyses.
22
CHAPTER FOUR
4.0 RESULTS
4.1 INTRODUCTION
The findings of the study are presented in this chapter. It is based on the objectives of
the study. The results are presented in tables and graphs. It involves a presentation of
the quantitative analysis of the background characteristics, knowledge, attitude and
practices towards inguinal hernia among adult-males in the East Mamprusi district.
4.2 BACKGROUND CHARACTERISTICS OF RESPONDENTS
Table 4.1 shows the percentage distribution of the respondents‟ background
characteristics. Majority (23.6%) of the respondents were within the age range of 21 –
30 years, with a mean age of 38 years. More than half (54.6%) of them practiced Islam.
Most (81.5%) of the respondents were married. Most (57.4%) of them however had no
formal education, with only about two percent having obtained a tertiary education.
Almost two-thirds (64.8%) were agricultural workers, with more than ninety percent of
them being northerners.
23
Table 4.1: Socio-demographic characteristics of respondents
Variables
Frequency (n) Percentage (%)
Age
≤ 20 32 14.8
21 – 30 51 23.6
31 – 40 44 20.4
41 – 50 37 17.1
51 – 60 31 14.4
61 – 70 17 7.8
71 + 4 1.9
Mean = 38, SD = 15.3
Religion
Christianity 28 13.0
Islam 118 54.6
Traditionalist 70 32.4
Marital Status
Single 35 16.2
Married 176 81.5
Divorced/ Widowed 5 2.3
Education level
No formal education 124 57.4
Primary 17 7.9
JHS 29 13.4
Secondary/Post-secondary 41 19.0
Tertiary 5 2.3
Occupation
Agricultural worker 140 64.8
Salaried employment 18 8.3
Trader 14 6.5
Daily laborer 1 0.5
Domestic activities 1 0.5
Student 33 15.9
Unemployed 1 0.5
Retired 3 1.4
Other 4 1.9
Tribe
Akan 3 1.4
Northerner 211 97.7
Ewe 2 0.9
Source: Field Data, 2013
24
4.3 PROPORTION OF RESPONDENTS WITH INGUINAL HERNIA
Of the 216 respondents interviewed (97.7% response rate), about 29 (14%) had inguinal
hernia while 180 (85.3%) did not have the condition (Figure 4.1).
Figure 4.1 Prevalence of Inguinal Hernia
Source: Field Data, 2013
4.4 ATTITUDES OF THE PROPORTION OF RESPONDENTS WITH
INGUINAL HERNIA TOWARDS SURGICAL TREATMENT.
Table 4.2 shows the attitudes of the proportion of respondents with inguinal hernia
towards surgical treatment. Out of the proportion of respondents with inguinal hernia
72.2% consulted a doctor, while only 27.6% did not see a doctor about their condition.
Also, majority (62.1%) of those living with inguinal hernia cited pains as the principal
reason for consulting a doctor, but only 3.5% cited Stigmatisation as their reason for
seeing a doctor about their condition. Again, out of those reported to have inguinal
hernia about 41.4% preferred medication for treatment of their condition, while only
24.1% of the proportion of respondents with inguinal hernia did not know the best of
treatment yet. Lastly, out of the 29 respondents who had inguinal hernia, about 31.0%
25
chose to have surgical operation of their inguinal hernias the next month, whereas only
13.8% of the proportion of respondents with inguinal hernia opted to have the operation
the very day they consulted the doctor.
Table 4.2: Attitudes of the proportion of respondents with inguinal hernia towards
surgical treatment.
Variable Frequency (n) Percentage (%)
Have you seen a doctor about
your hernia?
Yes 21 72.4
No 8 27.6
Reasons for seeing doctor
Pains 18 62.1
Disturbing size 2 6.9
Stigmatization 1 3.5
Don‟t know 8 27.6
How would you like the doctor to
treat your inguinal hernia?
Give me medicines that will make
the hernia go
Perform a surgical operation
12
10
41.4
34.5
Don‟t know 7 24.1
When would you like the doctor
Operate on you?
Today 4 13.8
Next month 9 31.0
Next year 8 27.6
Don’t know 8 27.6
Source: Field Data, 2013
26
4.5 HEALTH BEHAVIOURS
Table 4.3 shows a summary of respondents‟ life style in conjunction with inguinal
hernia occurrence. About eighty percent of the respondents reported to have ever
engaged in heavy lifting, with almost an equal number reporting the frequency of lifting
to be occasional. Twelve respondents (representing 8.4%) reported lifting heavy
objects prior to their inguinal hernia occurrence, a suspicion of possible cause of the
condition.
Table 4.3: Health Behaviors of the Respondents
Variable Frequency (n) Percentage (%)
Ever engaged in heavy lifting
Yes 167 80.0
No 39 18.6
Don‟t know 3 1.4
Frequency of lifting
Very often 16 8.8
Occasional 153 84.1
Once 1 0.6
Don‟t know 12 6.5
Lifting of heavy object prior to
inguinal hernia occurrence
Yes 12 8.4
No 6 4.2
Don‟t know 124 87.3
Source: Field Data, 2013
4.6 KNOWLEDGE ABOUT INGUINAL HERNIA
In order to assess the knowledge of the respondents with regard to inguinal hernia, two
sets of questions were asked which included the possible cause of the condition (Table
4.4). Majority (61.6%) of the respondents attributed the cause to hereditary factors.
More than half (52.7%) also reported food/drink to be the cause.
27
Table 4.4: Knowledge about Inguinal Hernia
Variable Frequency (n) Percentage (%)
Cause of Inguinal hernia
Spiritual/Curse/Witchcraft 68 32.2
Hereditary 130 61.6
Hard/manual work 5 2.4
Don‟t know 8 3.8
Food/drink cause inguinal
hernia
Yes 109 52.7
No 51 24.6
Don‟t know 47 22.7
Source: Field Data, 2013
4.7 ATTITUDE TOWARDS INGUINAL HERNIA DIAGNOSIS
Respondents were asked to indicate the step they will take when they suspect that they
may have inguinal hernia (Table 4.5). The predominant step reported was to “see a
doctor” (34.5%), followed by “inform a close relative” (28.7%) and “observe for a
while” (23.4%). The least reported was to “inform the priest/pastor” (1.4%). Almost
two-thirds (65.2%) reported that they will see a doctor within one month after
discovering a lump in their groin area.
28
Table 4.5: Attitude towards diagnosis of inguinal hernia
Variable Frequency (n) Percentage (%)
Suspicion about inguinal
hernia
Inform a close relative 60 28.7
Inform the priest/pastor 3 1.4
Seek spiritual intervention 10 4.8
Observe for a while 49 23.4
See the doctor the same day 72 34.5
Hide it as a protected secret 11 5.3
Inform the doctor only if the
hernia is painful 0 0.0
Use herbs before reporting to
doctor 4 1.9
How soon to see a doctor
after discovering lump in
groin area
After three months 16 7.7
Within one to three months 41 19.8
Within one month 135 65.2
Any time you are free 13 6.3
When you are able to make
some time 2 1.0
Source: Field Data, 2013
4.8 ATTITUDES TOWARDS INGUINAL HERNIA TREATMENT
Table 4.6 shows the percentage distribution of attitude of respondents towards
diagnosis of inguinal hernia. About 97.1% reported inguinal hernia to be curable. They
also indicated fear of surgery (28.8%) to be their major cause of delay in early
treatment, followed by adverse effect of surgery (25.4%) and high hospital cost
(24.5%). Majority (93.4%) believed an orthodox doctor could effectively treat inguinal
hernia. However, most of them (86.3%) had not seen a doctor to confirm their state of
hernia. Of the 20 respondents who met with their doctor concerning their state of hernia
did so because of pains (90.9%) and 9.1% disturbing size. Yet, less than half (43.5%)
29
indicated they will allow operation to be performed the next month while about one-
fifth (21.7%) indicated they would allow operation the same day after seeing any
unusual symptoms.
30
Table 4.6: Attitude towards inguinal hernia treatment.
Variable Frequency (n) Percentage (%)
Curability of inguinal hernia
Yes 205 97.1
No 2 1.0
Don‟t know 4 1.9
*Cause of delay in early
treatment
I don‟t have time/busy 0 0.0
High hospital cost 154 24.5
Delay at hospital 23 3.7
Fear of surgery 181 28.8
Adverse effect of surgery 160 25.4
Preference of traditional remedies 89 14.1
Observation 22 3.5
Practitioners who can
effectively treat Inguinal hernia
Spiritual pastor /spiritual
intervention 4 1.9
Herbalist / traditional doctor 10 4.7
Orthodox doctor 198 93.4
Seen a doctor about state of
hernia
Yes 23 13.1
No 152 86.3
Don‟t have hernia 1 0.6
Reasons for seeing doctor
Pains 20 90.9
Disturbing size 2 9.1
Stigmatization 0 0.0
Time to allow operation to be
performed
Today 5 21.7
Next month 10 43.5
Next year 8 34.8
Source: Field Data, 2013
31
4.9 MISCONCEPTIONS ABOUT INGUINAL HERNIA TREATMENT
Table 4.6 shows the percentage distribution of misconceptions about inguinal hernia
among the respondents. Though more than half (56.1%) did not believe inguinal hernia
is as a result of ancestral curse, about one-fifth of them however believed otherwise.
The predominant reason for which some respondents refused to have early treatment of
inguinal hernia was fear of death (28.8%), followed by the desire to hide it (16.4%).
The least reason indicated by the respondents was size of hernia being small (9.7%).
Almost half (46.4%) of the respondents believed “Pito” (a local beer) was the cause of
inguinal hernia. About 29.8% of the respondents also believed persons living with
inguinal hernia could experience pains during sexual intercourse. Majority of the
respondents also indicated that one can acquire inguinal hernia by laughing or insulting
(46.9%) and having sexual intercourse with someone‟s wife (43.1%) and also riding
bicycle (43.0%).
32
Table 4.7: Misconception about treatment of inguinal hernia
Variable Frequency (n) Percentage (%)
Inguinal hernia is the result of
ancestral curse
Yes 55 25.7
No 120 56.1
Don‟t know 39 18.2
*Why persons living with
inguinal hernia refuse to have
early surgical treatment
Soothsayers‟ advice 62 11.2
Desire to hide it 91 16.4
Size of hernia being small 54 9.7
Desire for more children 87 15.6
Fear of death 160 28.8
Preference of traditional remedies 63 11.3
Observation 39 7.0
Excessive drinking of Pito (local
beer) cause inguinal hernia
Yes 96 46.4
No 54 26.1
Don‟t know 57 27.5
Persons living with inguinal
hernia could experience pains
during sexual intercourse
Yes 62 29.8
No 37 17.8
Don‟t know 109 52.4
Inguinal hernia can be acquired
by laughing or insulting those
who have it
Yes 98 46.9
33
No 111 53.1
Inguinal hernia can be acquired
after having sexual intercourse
with someone’s wife
Yes 90 43.1
No 57 27.3
Don‟t know 62 29.7
Riding of bicycles can cause
inguinal hernia
Yes 40 43.0
No 94 27.3
Don‟t know 78 29.7
Source: Field Data, 2013 *Multiple Response
34
CHAPTER FIVE
5.0 DISCUSSION
5.1 Introduction
This chapter discusses the results of the study in relation to the objectives and key
variables of the research. The purpose of this study was to assess the knowledge,
attitudes and practices towards inguinal hernia among adult-male in the East Mamprusi
District.
Inguinal hernias by far are the most common types of hernias seen in most parts of
Africa. Previous studies have documented the magnitude of the condition with varying
proportions. In Ghana, the prevalence of inguinal hernia among adult men during the
1970s was estimated to be 7.7% compared with 30% found on the island of Pemba in
East Africa in 1969 (Belcher et al., 1978; Yardov and Stoyanoy, 1969). In this study,
the proportion of male adults with inguinal hernia for the past two years was estimated
to be 14%. This is somewhat alarming considering the fact that most cases of inguinal
hernia go untreated especially in resource-poor settings, and more prevalent in people
with low socio-economic status (Osifo and Amusan, 2010). Most of these cases are
therefore reported when complications set in. This results in increased therapeutic costs
for both the patient and the health system (Rutkow, 2003). In some cases as reported in
Niger, mortality from hernia strangulation even with access to surgical care is high -
40% (Hair et al., 2001).
5.2 Knowledge about Inguinal Hernia
In many developing countries, lack of awareness and financial constraints make many
patients present very late with giant inguinoscrotal hernia which is a serious life-
threatening condition (Osifo and Amusan, 2010). In this study, majority of the
35
respondents attributed the cause to hereditary control (61.6%) and food/drink
(52.7%).These findings are consistent with the work of Evans et al(93) that urogenital
diseases such as hydrocele is caused by genetic factors as well as over consumption of
sweet drinks such as palm wine or riding of bicycles( Evans, et al 1993 cited in
Frimpong, 2010).However, some studies have attributed risk of developing inguinal
hernia and its complications mainly to overweight, older persons, history of
haemorrhoids, smoking and hiatal hernia (Abramson et al., 1978; De Luca et al., 2004;
Sorensen et al., 2002). Inadequate knowledge about the signs and symptoms of the
condition has a devastating implication, not only with pain during strangulation but also
puts more weight on health facilities during emergency. This situation could therefore
be curtailed if the public is well sensitized about the nature of the disease.
5.3 Attitude towards the Diagnosis and Treatment of Inguinal Hernia
It has been documented that, people with inguinal hernia not only go through physical
pains but also psychological traumas as well (Salih, 2008). Anecdotal evidence
suggests that people living with the condition are usually ridiculed by the public. As a
result of this individuals with the condition usually hide their condition and refuse to
seek prompt treatment. The study revealed that most (28.7%) would rather inform a
close relative about a disease upon suspicion. Although a substantial proportion
(34.5%) said they would see a doctor the same day upon suspicion, it does not however
overwhelm the influence of peoples‟ attitude towards seeking early diagnosis.
Interestingly, about 23.4% would prefer to observe the condition for a while before
seeking medical checkup and 5.3% would prefer to hide it completely. This is
consistent with a study conducted by Salih (2008), where people with the condition
were found to have a poor health seeking behaviour. It was also revealed in this study
36
that majority (65.2%) would only seek medical attention within one month after
discovering a lump in the groin area.
Attitude is an internal or overt feeling or selective nature of intended behavior which
represents the affective domain (Bloom, 1956). The attitude towards inguinal hernia
treatment was assessed to help better understand how people feel about the condition.
The predominant reason revealed in this study ascribed to the cause of delay in early
treatment was found to be fear of surgery (28.8%), followed by adverse effect of
surgery (25.4%) and high hospital cost (24.5%). Fear of surgery as the cause of delay
has the propensity to further complicate the condition especially when it reaches the
stage of giant inguinoscrotal hernia, a precursor of hernia strangulation. The situation is
usually exacerbated when the populace believes spiritual pastors and herbalist are the
appropriate sources where their problem can be resolved. This was however not the
case as majority (93.4%) of the respondents in this study believes orthodox doctors can
effectively treat the condition. More than ninety percent of those who have the
condition reported to have seen a doctor because of the pains they feel, with majority
(43.5%) indicating they would only allow surgical operation the following month. This
clearly shows a poor health seeking behaviour and attitude towards inguinal hernia
treatment.
5.4 Misconception about treatment of inguinal hernia
Misconception, which is the wrong idea, thought or notion, could affect the health
seeking behaviours. Misconception about the treatment of inguinal hernia in this study
was found to be sufficient enough to affect an individual‟s health seeking behaviour.
About one-fourth of the respondents indicated that inguinal hernia is as a result of
ancestral cause. This proportion of individuals could therefore easily be swayed in
37
believing that herbalist could be their utmost source of solution. Majority (28.8%) of
them reported that persons with inguinal hernia refuse to have early surgical treatment
for fear of death. About 11.2% of the respondents also indicated that persons living
with inguinal hernia refuse to have early surgical treatment because of a soothsayer‟s
advice. This paints a clear picture of inadequate information about the aetiology of the
disease. This could be compounded depending on the socio-economic status and the
cultural believes of the people. The study also revealed that the predominant perception
among the respondents was that “Pito” (a local beer) could cause inguinal hernia.
About thirty percent of the respondents also believed people living with inguinal hernia
could experience pains during sexual intercourse, an opinion which was contrary to
about 17.8% of them, with one-half having no idea. Interestingly, almost one-half of
the respondents believed that one can acquire the disease by laughing or insulting those
who have the disease. Similarly, it was revealed in this study that the predominant
perception was that the disease can be acquired by having sexual intercourse with
someone‟s wife (43.1%) and riding bicycles (43.0%).
5.5 Practices related to inguinal hernia occurrence
Strenuous exertion activities have been linked with inguinal hernia as a possible risk
factor (Flich et al., 1992; Carbonel et al., 1993). Heavy physical exercise has therefore
been the subject of many statements and studies in past literature (Flich et al., 1992). It
was revealed in this study that majority (80%) of the respondents had ever engaged in
heavy lifting activity, with about 84.1% reporting its frequency to be occasional. Other
studies have also documented chronic increased in intra-abdominal pressure as an
etiologic factor for inguinal hernia, and this may therefore be provided by the
association between obstipation and hernia (Liem et al., 1997).
38
CHAPTER SIX
6.0 CONCLUSIONS AND RECOMMENDATIONS
6.1 CONCLUSIONS
This study highlighted inadequate knowledge, inappropriate attitudes and practices
towards inguinal hernia among adult-males in the East Mamprusi District.
6.1.1 Prevalence of Inguinal Hernia in the East Mamprusi District
In conclusion, the findings of the research showed that about 29 (14%) had inguinal
hernia.
6.1.2 Misconceptions (knowledge) about the causes of inguinal hernia
It is again conclusive that majority (61.6%) of the respondents attributed the cause of
inguinal hernia to hereditary factors, with more than half (52.7%) reporting food/drink
to be the cause. Also, Eighty percent of the respondents reported to have ever engaged
in heavy lifting, with almost an equal proportion (84.1%) reporting the frequency of
lifting to be occasional. Twelve respondents also reported lifting heavy objects prior to
their inguinal hernia occurrence. With respect to the misconception surrounding
inguinal hernia treatment, about one-fifth believed inguinal hernia is as a result of
ancestral curse, with about 56.1% believing otherwise. The predominant reason for the
respondents refusing early treatment was fear of death (28.8%), followed by the desire
to hide it (16.4%). Almost half (46.4%) of the respondents also believed “Pito” (a local
beer) was the cause of inguinal hernia, with 46.9%, 43.1% and 43.0% having the
perception that one could acquire the condition by laughing or insulting, having sexual
intercourse with someone‟s wife and riding bicycle respectively.
39
6.1.3 Attitudes towards inguinal hernia and people living with inguinal hernia
As regard attitude towards diagnosis of inguinal hernia, it is conclusive that majority
(34.5%) indicated they would see a doctor when faced with the conditions, with less
than two percent reporting that they would rather inform a priest/pastor. Moreover, the
predominant attitude towards the treatment of inguinal hernia among the respondents
was found to be fear of surgery (28.8%), followed by adverse effect of surgery (25.4%)
and high hospital cost (24.5%). Majority (93.4%) also believed an orthodox doctor
could effectively treat inguinal hernia.
6.2 Recommendations
These findings draw attention to the need for swift intervention. Stakeholders could
therefore use the findings of this study to demystify the aura of misconceptions and
perceptions surrounding inguinal hernia diagnosis and treatment.
DISTRICT HEALTH DIRECTORATE
The District Health Management Team (DHMT) need to observe the following:
1. Ensure that Information, education and communication (IEC) programmes are
intensified in order to demystify the wrong perceptions and practices people have about
the condition. This could be done by using local information centers as a platform for
providing wider range of education. This would not only increase their knowledge but
also help them identify initial signs and symptoms of the condition in order to prevent
strangulation. Behaviour Change Communication (BCC) programmes as with IEC
would help to undo the deep seated beliefs among the people of East Mamprusi that
having inguinal hernia is as a result of ancestral curse. What remains centrally funny is
the uncontested belief that anybody who buries any dead persons that have inguinal
hernia could easily contract inguinal hernia unless undertakers who are spiritually
40
fortified to bury such victims of inguinal hernia without contracting the condition in
question..
2. Organize hernia related outreach programmes in the community. The programmes
could involve practical demonstration of how to identify early signs and symptoms,
including how effective the orthodox medicine allows for diagnoses and treatment of
the condition. This could help them better understand how inguinal hernia services are
provided and indirectly increase their confidence in orthodox medicine as the ultimate
source of effective inguinal hernia treatment.
3. Ensure that further research is conducted using qualitative and other quantitative
approaches (e.g. Case-Control Study) to better understand the aetiology of the
condition and whether efforts to provide IEC under the new programmes have
improved their knowledge about the condition. This is expected to help better
understand the cognitive level of the people with regard to inguinal hernia in order to
provide the appropriate services.
DISTRICT ASSEMBLY
The district assembly could use the results of this study to guide and facilitate efforts
needed by other agencies including Non-Governmental Organisations (NGOs),
Community Based Organisations (CBOs) and the like to provide interventions which
are geared towards the improvement of surgical services in the district.
MISTRY OF HEALTH (MOH)
The MOH could ensure that all health service outlets are adequately equipped in order
to provide the needed treatment and diagnosis of the condition.
41
REFERENCES
Abramson, J. H., Gofin, J. and Hopp, C. (1978). The epidemiology of inguinal hernia.
A survey in western Jerusalem. J Epidemiol Community Health 1978;32:59–67.
Adongo, P. B., Kirkwood, B. and Kendall, C. (2005). How Local Community
Knowledge About Malaria Affects Insecticide-Treated Net Use In Northern
Ghana. Tropical Medicine & International Health, 10:366-378.doi:
10.1111/j.1365-3156.2005.01361.x.
Akin, M. L., Karakaya, M., Batkin, A. and Nogay, A. (1997). Prevalence Of Inguinal
Hernia In Otherwise Healthy Males of 20-22 years of age. Retrieved from
http://www.ramcjournal.com/content/143/2/101.full.pdf (Accessed: 23rd July,
2013).
Antoinette S.(2010) Alternative Medicine In Ghana Part Two: Herbal Remedies for the
Common Cold. Retrieved www.jhr.calblog/2010/10/alternative-medicine-in-
Ghana-part-two-herbal-remedies-for-the-common-cold.
Belcher, D.W., Nyame, P.K. and Murapa, F. K. (1978). The Prevalence Of Inguinal
Hernia In Ghanaian Males. Trop Georgr Med 30:39–43
Bloom, B. S. (1956). Taxonomy Of Educational Objectives, The Classification Of
Educational Goals – Handbook I: Cognitive domain, New York: David Mackay.
Burkitt D.P.(1972).Varicose Veins, Deep Vein Thrombosis, And Haemorrhoids:
Epidemiology And Surgical Aetiology.Br Med J.
Carbonell, J. F., Sanchez, J. L. and Peris, R. T. (1993). Risk Factors Associated With
Inguinal Hernias: A Case Control Study. Eur J Surg;159:481–6.
42
Caris, E. G., Kendra, G. B., Christopher, M. D. and Christopher, B. D. (2011).
Systematic Review Of Barriers To Surgical Care In Low –Income and Middle-
Income Countries. World Journal of Surgery (2011) 35:941-950.
Caris, E. G., Rebekah, S. L. Law, Eric, S. Borgstein, N. C. Mkandawire, Christopher,
B.D (2012). Systematic Review of Met and Unmet Need Of Surgical Disease In
Rural Sub-Saharan Africa. World Journal Of Surgery Publication (2012) 36:8-
23.
De Luca, L., Di Giorgio, P. and Signoriello, G. (2004). Relationship Between Hiatal
Hernia and Inguinal Hernia. Dig Dis Sci;49:243–7.
Drucker, S. (1975). Ritual Aspects of the Mamprusi Kingship: African Social Research
Documents. Volume 8.
Ellen, V. (2009). Concepts and Challenges In The Use of Knowledge-Attitude- Practice
Surveys : Literature Review. Retrieved from:
http://www.snndz.net/app/download/5095663611/concepts and challenges in the
use of knowledge-attitude-practice (Accessed: 5th August, 2012).
Eshah, N.F., (2011), .Lifestyle And Health Promoting Behaviours In Jordanian
Subjects Without Prior History Of Coronary Heart Disease, Zarqa Private
University, Faculty of Nursing, Zarqa, Jordan.
Flich, J., Alfonso, J. L. and Delgado, F. (1992). Inguinal Hernia And Certain Risk
Factors. Eur J Epidemiol;8:277–82.
Frimpong, S. (2010). Effects of Lymphatic Filariasis On The Socio-Economic Life Of
The People Of Narkwa In The Mfantseman Municipality Of The Central Region
of Ghana.
Garba, E. S. (2000). The Patterns Of Adult External Abdominal Hernias In Zaria. Nig J
Surg Res, 2(1):12–15.
43
Ghana AIDS Commission (2006).NAT.RESPONSE-Alert School Model-HIV
Programme Report Final for UNICEF. Retrieved
http://www.ghanaaids.gov.gh/gac/publications/viewdoc.php?docID=120(Accesse
d: 19th
May, 2012).
Ghana Districts(2006).East Mamprusi District Assembly: Location and Size
Retrieved from http://www.eastmamprusi.ghanadistricts.gov.gh/
Ghana Districts(2006).Health Sector-East Mamprusi District.
Retrieved from http://www.eastmamprusi.ghanadistricts.gov.gh/
Ghana Statistical Service (2012). 2010 Population And Housing Census Final Results.
Retrieved from http://www.statsghana.gov.gh/docfiles/2010phc/2010
Hair, A., Paterson, C. and Wright, D. (2001). What Effect Does The Duration Of An
Inguinal Hernia Have On Patient Symptoms? J Am Coll Surg 193:125–129
Harouna, Y., Yaya, H. and Abdou, I. (2000) Prognosis Of Strangulated Hernia In
Adults With Necrosis Of Small Bowel: A34 Cases Report.Bull Soc Pathol Exot
93:317–320
Harvard Health Publications (2013). Inguinal Hernia Guide: Causes, Symptoms And
Treatment Options. Retrieved from http://www.drugs.com/health-guide/inguinal-
hernia.html (Accessed: 24th June, 2013).
Kingsnorth, A. N. and LeBlanc, K. A. (2003). Management Of Abdominal Hernias. 3rd
edition. London, New York: Edward Arnold; 2003:40–47.
Kingsnorth, A. N., Clarke, M. G. and Shillcut, S. D. (2009). Public Health and Policy
Issues of Hernia Surgery in Africa: World Journal of Surgery.
Kochanek, K. D., Murphy, S. L. and Anderson, R. N. (2002). Deaths: Final Data for
2002,Hyattsville, MD: National Center for Health.
44
KNUST and KATH (2013).Knowledge, Attitudes and Practices towards Inguinal
Hernia (Unpublished work)
Liem, M. S., van der Graaf, Y. and Zwart, R. C. (1997). Risk Factors for Inguinal
Hernia in Women: A Case-Control Study of The Coala Trial Group. Am J
Epidemiol;146:721–6.
McDonough, S., Paula, D. and Baxter, D. (2007). Complementary and Alternative
Medicine: Patterns of Use in Northern Ireland, ARK Social and Political Archive
Research Updates NO.50.
Retrievedhttp://www.ark.ac.uk/publications/updates/updates 50.pdf (Accessed: 24th
February, 2013).
National Digestive Information Clearinghouse (2008): Inguinal Hernia, National
Institutes of Health Publication.
http://digestive.niddk.nih.gov./diseases/pubs/inguinalhernia/ (Accessed: 20th
March, 2013).
Nesterenko, I. V. A. and Shovskii, O. L. (1993). Outcome Of Treatment Of
Incarcerated Hernia. Khirurgiia (Mosk), 9:26–30.
O‟Donnell, O. (2007). Access to Health Care In Developing Countries: Breaking Down
Demand Side Barriers. Cad Saude Publications.
Ohene-Yeboah, M. and Abantanga, F. A. (2011). Inguinal Hernia Disease In Africa: A
Common But Neglected Surgical Condition. West African Journal of Medicine .
Osifo, O. D. and Amusan, T. I. (2010). Outcome Of Giant Inguinoscrotal Hernia Repair
With Local Lidocaine Anaesthesia. Saudi Med J 2010, 31(1):53–58.
Primatesta, P. and Golacre, M. J. (1996). Inguinal Hernia Repair, Incidence of Elective
And Emergency Surgery. Int J Epidemol 1996, 25:835–839.
45
Rai, S., Chandra, S. S. and Smile, S. R (1998). A Study Of The Risk of Strangulation
And Obstruction in Groin Hernias. Aust N Z J Surg 1998, 68:650–654.
Rutkow, I. M (2003). Demographic And Socioeconomic Aspects Of Hernia Repair In
The United States in 2003. Surg Clin North Am, 83:1045–1051.
Rutkow, I. M. (2003). Demographic and Socio-Economic Aspects Of Hernia Repair In
The United States in 2003. Surg Clin North Am 83:1045–1051.
Salih, I. (2008): Sudan Journal of Medical Sciences; Giant Hydrocele Retrieved from
www.sudjms.net/issues/3-1/pdf/14-Giant hydrocele.pdf (Accessed: 15th April,
2013).
Sanders, D. L., Porter, C. S., Mitchell, K. C. D., Kingsnorth, A. N. (2008). A
Prospective Cohort Study Comparing the African and European Hernia.
http://www.ncbi.nlm.nih.gov/pubmed/18404299(Accessed: 16th July, 2013).
Sarpong, A. (2011). Alternative Medicine in Ghana Part Two: Herbal Remedies for the
Common Cold. Retrievedhttp://www.jhr.ca/blog/2010/10/alternative-medicine-
in-ghana-part two-herbal-remedies-for -the-common-cold/ (Accessed: 21st
December, 2010).
Schools, I. G., Van Dijkman, B., Butzelaar, R. M., Van Geldere, D. And Simons, M. P.
(2001). Inguinal Hernia Repair In Amsterdam Region. Hernia 2001, 5(1):37–40.
Shillcut, S. D., Clarke, M. G. and Kingsnorth, A. N. (2010). Cost-Effectiveness of
Groin Hernia Surgery in the Western Region of Ghana. National Institutes of
Health Publication http://www.ncbi.nlm.nih.gov/pubmed/20956763 (Accessed:
1st August, 2013).
Sorensen, L. T., Friis, E., Jorgensen, T. (2002). Smoking Is A Risk Factor For
Recurrence Of Groin Hernia. World Journal of Surgery 2002; 26:397–400.
46
Stewart, D. (2013). Differences Between Conceptual & Theoretical Frameworks, eHow
Publications. Retrieved from http://www.ehow.com/info_8769890_difference-
between conceptual-and-theoretical framework.html (Accessed: 19th June, 2013).
World Health Organisation (2001). Legal Status Of Traditional Medicine and
Complementary/Alternative Medicine: A World Review.
Retrieved from http://www.who.int/medicinedocs/en/d/jh2943e/4.18 html (Accessed:
2nd May, 2013).
Williams, N. S., Bulstrode, C. J. K. and O‟Connell, P. R. (2008). Bailey & Love‟s
Short Practice of Surgery. 25th edition. London: Hodder Arnold.
World Health Organization (2002). Surgical Approaches To the Urogenital
Manifestations of Lymphatic Filariasis. retrieved from:
WHO/CDS/CPE/CEE/2002.33 (Accessed: 27th
September, 2013).
World Health Organization (2004). How To Investigate The Use of Medicines By
Consumers. Retrieved from: who.int/medicinedocs/en/d/js6169e/7.html
(Accessed: 7th
May, 2012).
Yardov, Y. S. and Stoyanov, S. K. (1969). The Incidence Of Hernia On The Island Of
Pemba. East African Med J 46:687–691
Zohixin, Li. (2011).Natural Ways To Treat Hernia-Beijing Today. Retrieved from
http://www.bjtoday.ynet.com/3.3/1105/20/5988739.html (Accessed: 21st April,
2012).
47
APPENDICES
APPENDIX A
QUESTIONNAIRE
SCHOOL OF GRADUATE STUDIES
KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY
DEPARTMENT OF COMMUNITY HEALTH
Topic: Assessment of Knowledge, attitudes and practices towards inguinal
hernia among adult-males in the East Mamprusi District, Ghana.
Introduction: This questionnaire is designed to obtain information on
knowledge, attitudes and practices towards inguinal hernia among adult-males
(aged 15 years and above) in the East Mamprusi District of Ghana. I wish to
acknowledge that some of the questions of the questionnaire are personal and
confidential. However, it is hoped that you would offer genuine and honest answers to
all questions contained in this questionnaire. You are reminded that your answers are
used purposely for this research and would not be used in any ways to harm or
disgrace you. Thank you.
48
N am e o f C omm un i ty ………………………………………..
Section A. Background Information - So c i o - eco nom i c s ta tus
Relation
(to head)
Age M a r i t a l
S t a t u s
E d u c a t i o n O c c u p a t i o n R e l i g i o n T r i b e
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
H o u s e h o l d
I D
What is
[name]’
relation
to the
head of
the
family?
How old
is
[name]?
What is
[name]’s
current
marital
status?
How many
years of
schooling
did [name]
complete?
What is
the
highest
school
level
[name]
did?
What is
[name]’s
main
occupa-
tion?
What is
[name]’s
second
occupa-
tion?
What is
your
religion?
What is
your
tribe?
W h a t i s y o u r f a m i l y s i z e _ _ _ _ _ _ _ _
49
CODES: Household Members Registration Form
Relation
(to head)
Marital
status
Education Occupation Religion Tribe
Q1 Q3 Q5 Q6&Q7 Q8 Q9
01=Head
02=Child
03=Nephew
04=Uncle
05=Other
07=parent
of the head
1=married
2=divorced
3=separated
4=widow
5=single
(never
married)
0=No school
1=Primary school
2= Senior High
school
3= Junior High
school
4=College/University
5=Post-secondary
1=Agricultural
worker
(including
animal care),
own field
2=Agricultural
wage-labor,
for cash or in
kind
3=Salaried
employment
4=Petty trader
/marketing
5=Daily
laborer
6=Domestic
activities
7=Student
8=Unemployed
9=Retired
10=Other
88=Don‟t
know
1=Christianity
2=Islam
3=Traditional
88=None
1=AKan
2=Northerner
3=Ewe
4=Ga
5=other
50
NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP
HOUSING CONDITIONS
I would like to start by asking you a few questions about your house.
Q10 Will you please describe your family‟s
housing situation?
( CIRCLE THE ONE MOST
APPROPRIATE)
We rent a room ............................... 1
We rent an apartment ...................... 2
We rent a house............................... 3
We rent part of a house ................... 4
We live in a dormitory .................... 5
We live in an apartment that we own 6
We live in a house that we own ...... ..7
We live in part of a house that we own
........................................................ 8
Other ...............................................
___________________
___________________
Q11 How much do you pay for your home per
month?
[INTERVIEWER: IF RENT IS PAID ON
AN ANNUAL BASIS, DIVIDE THE
AMOUNT BY 12]
GH¢…………………………………..
Q12 What is the main source of water your
household uses for drinking?
[INTERVIEWER: BE SURE OF THE
SOURCE OF “PIPED WATER”. IF THE
ANSWER IS “PIPED WATER” CHECK
THE SOURCE AND CIRCLE THE
APPROPRIATE CODE]
Piped water/supply water
Piped inside dwelling …………..11
Piped to yard/plot……………….12
Public tap……………………… 13
Water from open well/spring
Open well/spring in yard/plot…..21
Open public well/spring………. 22
Water from protected well/spring
Protected well/spring in
yard/plot…………………………..31
Protected public well/spring…….32
51
Water from borehole
Borehole in yard/plot……………41
Public borehole………………….42
Surface water
Pond/lake………………………..51
River/stream/spring……………..52
Dam…………………………….....53
Rain water………………………...61
Tanker truck………………………62
Vendor... ………………………….63
Bottled water…….........................64
No fixed facility………………….71
Other …………………………….81
INDIVIDUAL LAND AND FARMS
And now a few questions about land and farming.
Q13 Tell me, please, does your family have (do
you have) any land at your disposal?
(IF NO, SKIP TO Q24)
Yes .................................................. 1
No.................................................... 2
Don‟t know ..................................... 88
Q14 What is the total number of land plots now
at your disposal?
|__|__| land plots
Don‟t know ..................................... 88
Q15 What is the size of all the land your family
has at its disposal?
[INTERVIEWER: PROBE FOR AN
ESTIMATE]
|__|__||__|__||__|__| hectare
Don‟t know ..................................... 88
Q16a Tell me, please, does your family pay for Yes .................................................. 1
52
using that land? (IF NO,SKIP TO Q17a)
No.................................................... 2
Don‟t know………………………88
Q16b How much did your family pay for using
that land in the last year?
|__|__||__|__||__|__ | ____ GH¢______
Don‟t know………………………..88
Q17a Tell me, please, is your family paid by
others for the use of this land?(IF NO, SKIP
TO Q18)
Yes .................................................. 1
No.................................................... 2
Don‟t know………………………..88
Q17b How much did your family receive for the
use of the land in the last year?
|__|__||__|__||__|__| ____ GH¢______
Don‟t know………………………..88
Q18 What is the main use of this land?
( CIRCLE THE MOST APPROPRIATE)
Recreation only; nothing is grown here.
........................................................ 1
Crops for family use only, not for
market ............................................. 2
Crops for both family and market ... 3
Crops for market only ..................... 4
Just started developing land ............ 5
Residential ...................................... 6
Other ............................................... 7
___________________
___________________
Don‟t know………………………..88
Q19 Tell me, please, is anything grown on your
land?
Yes .................................................. 1
No.................................................... 2
Don‟t know……………………….88
Please tell me if you have the following on your farm:
Draught animals or farm machinery Q20. Own/rent
Q21. How much did you pay for
rent of land in the last year?
GH¢_________
a) Draught animals Own.......1 Rent.......2
53
b) Wheelcarts, wheelbarrows, sledges
c) Water pump
d) Power unit
e) Tractor, mini-tractor
f) Truck
Own.......1 Rent.......2
Own.......1 Rent.......2
Own.......1 Rent.......2
Own.......1 Rent.......2
Own.......1 Rent.......2
Q22 Now I would like to know whether you or
your family keep any poultry, livestock, or
bees?
(IF NO, SKIP TO Q24)
Q23 How many of the following animals do you
keep?
a) Cows, buffaloes ................. |__|__|
b) Young cattle....................... |__|__|
c) Pigs .................................... |__|__|
d) Sheep, goats ....................... |__|__|
e) Horses ................................ |__|__|
f) Rabbits............................... |__|__|
g) Poultry ............................... |__|__|
h) Number of Bee Hives ........ |__|__|
SPENDING AND SAVINGS
Let‟s talk a little about your spending. I would like to remind you that when you talk about your family,
it should apply to all those who share your residence & budget. We understand that you may not
remember exact figures.
Q24 How much money did you spend on food in
the last 7 days?
|__|__||__|__||__|__| GH¢___________
Don‟t know………………………..88
Q25 Does your family have any savings (in a
bank, value of stocks, jewelry or any
other)? If yes, please tell me the
approximate value.
[INTERVIEWER: MARK 0 IF NO
|__|__||__|__||__|__| GH¢___________
Don‟t know………………………..88
54
SAVINGS]
CARING FOR CHILDREN
Let‟s now talk about your children‟s care.
Q26 If your family has children of pre-school
age, please tell me where are these children
cared for, most of the time?
(IF NO, SKIP TO Q29)
In the family:
By parents themselves………….11
By close relatives………………12
By other individuals……………13
In relatives‟ home:
On father‟s side………………..21
On mother‟s side ……………...22
In pre-schools:
Run by the Government ……….31
Run by an enterprise or
organization……………………….32
Cooperative or private ………….33
Elsewhere…………………………41
___________________
Don‟t know……………………….88
Q27 Did any persons other than members of
your family who are not residing with you
help care for your children during the last 7
days?
Yes .................................................. 1
No.................................................... 2
Don‟t know………………………88
Q28 In all, what sum of money did you pay for
child-care in the last month?
|__|__||__|__||__|__| GH¢___________
Don‟t know………………………88
FAMILY INCOME
55
And now we would like you to talk about your family‟s budget, the size and sources of your income.
Q29 First of all, please tell me to what extent are
you satisfied with your family‟s present
income level?
Not at all satisfied ........................... 1
Less than satisfied ........................... 2
Rather satisfied ............................... 3
Fully satisfied .................................. 4
Don‟t know………………………..88
Q30 In the last month did your family receive
any assistance in kind (food, clothing, other
items) from persons who are not members
of your household?
(IF NO,SKIP TO Q32)
Yes .................................................. 1
No.................................................... 2
Don‟t know………………………88
Q31
Who provided the assistance? How are
these persons related to you?
(INTERVIEWER: CIRCLE ALL THAT
APPLY)
Children .......................................... 1
Grandchildren ................................. 2
Parents ............................................. 3
Grandparents ................................... 4
Other relatives ................................. 5
Friends/persons not related to you .. 6
Don‟t know………………………88
HEALTH SERVICE USE AND MEDICAL EXPENDITURE
Now I‟d like to ask about your family‟s medical care experiences.
MEDICAL EXPENDITURES
Q32 If you developed inguinal Hernia and
needed to pay for medical care, who would
pay for your medical expenses?
[NTERVIEWER: CIRCLE ALL THAT
APPLY]
Me ................................................... 1
My spouse/partner........................... 2
Other family members .................... 3
My employer ................................... 4
Use government (free) services ...... 5
Health insurance ............................. 6
Other ...............................................
___________________
56
Don‟t know………………………..88
Q33 What is the maximum amount that you are
willing to pay for medical services?
GH¢………………………………..
Q34 Did any member of your family spend
money on health insurance?
Yes .................................................. 1
No.................................................... 2
Don‟t remember…………………..88
Q35 How many of your family members are
covered by health insurance?
|__ _| adult males
|____| children (< 15 years of age)
Q36 Did any of your family members including
yourself require more money for health and
medical care in the last one year than you
could afford to spend?
Yes .................................................. 1
No.................................................... 2
Don‟t know………………………..88
Q37 Have you borrowed money from others to
meet your own or family members‟ medical
and health care expenses?
Yes .................................................. 1
No.................................................... 2
Don‟t know………………………..88
SECTION B. THE CAUSES OF INGUINAL HERNIA
Q38 Do you consider inguinal
hernia as a serious disease?
Yes ................................................... 1
No .................................................... 2
Don‟t know ...................................... 88
Q39 What do you believe is the
cause of inguinal hernia?
(INTERVIEWER:CIRCLE
ALL THAT APPLY)
Spiritual/Curse/Witchcraft ………………1
Hereditary ………………………………2
Hard/manual work ……………………...3
Cause not known ……………………….4
Don‟t know ...................................... …..88
57
Q40 Do you have inguinal hernia? Yes
…………………………………………...1
No
…………………………………………..2
Don‟t know ...................................... …..88
Q41 Can specific food/drink cause
inguinal hernia?
Yes
……………………………………………1
No
……………………………………………2
Don‟t know ...................................... …...88
Q42 If yes, name the type of food /
drink
[MENTION ALL THAT YOU
KNOW]
Q43 Have you ever engaged in
lifting heavy objects before? (IF
NO SKIP TO Q47)
Yes
……………………………………………1
No
……………………………………………..2
Don‟t know ...................................... …….88
Q44 If yes, what kind of objects?
[MENTION ALL THAT YOU
KNOW]
Q45
What was the frequency of
lifting the object?
Very
often……………………………………..1
58
Occasional…………. ...................... ……2
Once ...…………………………………..3
Don‟t know ...................................... …..88
Q46 Prior to the occurrence of your
inguinal hernia, did you lift any
heavy object?
Yes
…………………………………………….1
No
…………………………………………….2
Don‟t know ...................................... …….88
SECTION C. ATTITUDE TOWARDS INGUINAL HERNIA DIAGNOSIS
Q47 If you suspect that you have
inguinal hernia, what will you do?
(SELECT ALL THAT APPLY)
Inform a close relative………………..1
Inform the priest/pastor ……………...2
Seek spiritual intervention …………...3
Observe for a while …………………..4
See the doctor the same day …………5
Hide it as a protected secret ………….6
Inform the doctor only if the hernia is
painful……………………………….7
Use herbs before reporting to doctor …8
Other actions ……………………….
Q48 If you discover a lump in your
groin how soon do you see a
doctor?
After three months……………………..1
Within one to three months…………....2
Within one month……………………...3
59
(CIRCLE THE MOST
APPROPRIATE)
Any time you are free………………….4
When you are able to make some
time…………………………………….5
SECTION D. ATTITUDES TOWARDS INGUINAL HERNIA TREATMENT
Q49 Is inguinal hernia curable Yes .................................................. ….1
No .................................................... …2
Don‟t know ..................................... .88
Q50 What in your opinion often causes
delay in early treatment of inguinal
hernia (including your s)?
(SELECT ALL THAT APPLY)
I don‟t have time/busy .… …………1
High hospital cost……………………2
Delay at hospital …………………...3
Fear of surgery …………………….4
Adverse effect of surgery ……………5
Preference of traditional remedies …...6
Observation …………………………..7
Don‟t know………………………….88
Q51 In your opinion, which of the
following practitioners can
effectively treat Inguinal hernia?
(CIRCLE THE MOST
Spiritual pastor /spiritual
intervention………………………..1
Herbalist / traditional doctor …….2
Orthodox doctor …………………3
60
APPROPRIATE)
Other treatment options ……………
Q52
Have you seen a doctor about your
hernia?
(IF NO,SKIP TO Q56)
Yes …………………………………1
No …………………………………2
Don‟t have hernia…………………9
Q53 Reasons for seeing the doctor? Pains ………………………………1
Disturbing size .…………………..2
Stigmatization …………………….3
Other ………………………………
Q54 How will you like the doctor to
treat your hernia?
Give me medicines that will make the
hernia go ……………………………1
Perform a surgical operation ……….2
Other …………………………………
Q55 When would you like the doctor to
operate on you?
Today …………………………….1
Next month ...................................... …2
Next year …………………………….3
61
SECTION E. MISCONCEPTIONS ABOUT INGUINAL HERNIA TREATMENT
Q56 Is inguinal hernia the
result of ancestral curse?
Yes ................................................... 1
No .................................................... 2
Don‟t know ...................................... 88
Q57 Why do you think persons
living with inguinal hernia
refuse to have early
surgical treatment (
including you)?
(SELECT ALL THAT
APPLY)
Soothsayers‟ advice………………………..1
Desire to hide it…………………………….2
The size of hernia being small………………3
Desire for more children………….………..4
Fear of death…….. ………………….........5
Preference of traditional remedies ………..6
Observation …………………………………7
Don‟t know………………………………….88
Q58 Can excessive drinking of
pito (local beer) cause
inguinal hernia?
Yes……………………………………………1
No……………………………………………..2
Don‟t know ………………………………… 88
Q59 Do you think persons
living with inguinal
hernia could experience
pains during sexual
intercourse?
Yes ……………………………………………1
No ……………………………………………..2
Don‟t know…………………………………..88
Q60
Can you get hernia from
Yes…………………………………………….1
62
insulting or laughing at
those who already have
inguinal hernia?
No ……………………………………………..2
Q61 Is it possible to get hernia
from having sexual
intercourse with
somebody‟s wife?
Yes……………………………………………..1
No………………………………………………2
Don‟t know……………………………………88
Q62 Does riding of bicycles
cause inguinal hernia?
Yes………………….…………………………..1
No .................................................... ………….2
Don‟t know ………………………………….88
Thank you for your participation
APPENDIX B
The map below represents a map of the study area (East Mamprusi District) showing
the study communities.
63
Figure 1.0 Map of the East Mamprusi District showing the study towns.
Source: University of Cape Coast: Department of Geography and Regional
Planning, Remote Sensing Cartographic Laboratory (2013).